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Questions and Answers
Which of the following is NOT included in the demographic data of a health history?
The Review of Literature provides midwives with outdated information.
False
What is the main reason for documenting the Chief Complaint (CC) in a patient's history?
To record the patient's primary reason for seeking healthcare.
The systematic data collection method that uses observation skills to detect health problems is called __________.
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Match the following types of psychosocial assessments with their descriptions:
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What is the highest priority in preparing a client for a physical examination?
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The order of physical assessment should be conducted in a systematic method from feet to head.
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What should a client be asked to do before beginning a physical examination?
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During inspection, the examiner uses different senses such as the eyes, ears, and _____ to detect normal characteristics and abnormalities.
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Match the type of palpation with its description:
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Which sense is primarily involved in palpation?
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The midwife should examine clients from the side opposite of her dominant hand.
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What method involves striking a body part to elicit sounds or vibrations?
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Which type of priority involves a threat to vital functions like breathing and heartbeat?
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Medium Priority includes issues that may delay development or cause destructive changes.
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What is the importance of a client-centered plan of care?
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A midwife's independent actions do not require __________ from other persons.
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Which of the following is an example of an indirect intervention?
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Which of the following is NOT a part of the family assessment process?
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Match the following types of intervention with their descriptions:
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Setting goals and objectives is a part of the planning process in family care.
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What should selected interventions prioritize to be effective?
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Interdependent actions require collaboration with other members of the health team.
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What should be included in the initial data base of a family assessment?
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During the home assessment, it is important to observe __________ practices such as hand washing.
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Match the components of family assessment with their descriptions:
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What is the focus of the post-visit phase of family assessment?
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It is important to teach the family using only verbal explanations.
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What is one way to prevent the spread of infection during family assessments?
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What is the primary purpose of documentation in the healthcare process?
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During the evaluation phase, a midwife only determines if the outcomes were completely met.
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What should a student midwife do one week prior to their scheduled date of duty?
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The midwife conducts a home visit to seek ________ from the family before entering their home.
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Match the phases of home visits with their corresponding activities:
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Which of the following is NOT a component of preparing for a home visit?
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A spot map must always have North at the bottom.
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What is the purpose of establishing rapport with the family during a visit?
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Study Notes
Contents of Health History
- Demographic data includes information like name, address, phone number, sex, age, marital status, religion, and race.
- Chief Complaint (CC) is the main reason for seeking healthcare or consultation. It's recorded in the patient's own words.
- Past history includes childhood diseases, immunizations, allergies, past hospitalizations and diseases, accidents, injuries, and past and current medications.
- Review of systems is a head-to-toe rundown of the patient's present health status. It contains only subjective data given by the patient.
Review of Literature
- Journal, textbook, and research findings can provide additional information about a client's condition, allowing for better care and intervention.
- Reviewing related literature provides midwives with continual education to stay up-to-date with recent trends and advances in healthcare and midwifery practice.
Psychosocial Assessment
- Vocation/education/financial details the client's employment status, educational background, and financial situation.
- Home and family explores the client's living arrangements, family structure, and dynamics.
- Social, leisure, spiritual, and cultural aspects of the client's life are assessed, understanding their social networks, hobbies, beliefs, and cultural influences.
- Sexual history is evaluated to understand the client’s sexual practices and any related concerns.
- Activities of daily living assesses the client's ability to perform basic self-care tasks such as dressing, bathing, and eating.
- Health habits explore the client's lifestyle choices, including diet, exercise, and substance use.
- Psychological aspects of the client's well-being are assessed, including mood, anxiety, and coping mechanisms.
Physical Examination
- Physical assessment uses observation skills to detect health problems.
- Environmental considerations include a private and quiet space, good lighting, and a well-equipped examining room.
- Equipment preparation involves hand washing, ensuring proper table height, and organizing necessary instruments.
- Client preparation emphasizes psychological preparation through rapport building, explanation of procedures, and ensuring the client feels comfortable and at ease.
- Physical preparation includes asking the client to use the toilet before the examination and making them comfortable.
- Positioning involves understanding the appropriate position for the examination, considering any limitations or modifications needed.
- Order of Assessment is typically Cephalocaudal (head to toe).
- Inspection utilizes the senses of sight, hearing, and smell to observe normal characteristics and abnormal manifestations.
- Palpation involves using touch to assess texture, temperature, vibration, position, size, consistency, mobility, distention, tenderness, and pain.
- Light touch uses the pads of the fingers to identify areas of tenderness.
- Deep touch utilizes two hands, one palpating and the other supporting, to press deeper into the patient's abdominal area.
- Percussion involves striking a body part to elicit sounds or vibrations. The density of the underlying tissue determines the sound produced.
Priority Setting
- Priority setting determines which problems require the most immediate attention.
- General guidelines for priority setting include addressing immediate life-threatening issues first, focusing on vital functions (breathing, heartbeat, blood pressure), then addressing health-threatening problems, and finally addressing normal developmental needs or minimally supportive issues.
- First priority addresses any threat to vital functions (breathing, heartbeat, blood pressure).
- Medium priority involves health-threatening problems that may result in delayed development or cause destructive physical or emotional changes.
- Low priority includes problems arising from normal developmental needs or those requiring minimal nursing support.
Plan of Care
- The Plan of Care is client-centered, focusing on what the patient will experience or achieve at the completion of care.
Implementation/Intervention
- Intervention is putting the care plan into action.
- Direct Intervention involves actions performed through interaction with clients, like performing a temperature reduction technique on a client with fever.
- Indirect Intervention involves actions performed away from the client, like maintaining a specific temperature in the nursery to prevent heat loss in newborns.
- Intervention Selection requires choosing safe, legal, and medically compatible strategies.
Functions of Midwife
- Independent actions are those performed by the midwife without orders from others, including tasks like performing a temperature reduction technique or monitoring pregnant women.
- Dependent actions are those performed by the midwife following orders from a superior, such as following a doctor's orders.
- Interdependent actions are those performed in collaboration with other members of the health team, such as taking a urine specimen and delivering it to the laboratory.
Documentation
- Documentation is an important part of the intervention or implementation phase, ensuring accountability and continuity of care.
Evaluation
- Evaluation assesses the patient's response to nursing interventions, comparing them to the goals or outcome criteria written in the nursing plan to determine the extent to which care goals have been achieved.
- The midwife determines if the outcome criteria are completely met, partially met, or not met at all.
Family Case Load Guide
- Communication letter should be delivered to the head of the Barangay (Barangay Captain/Chieftain) a week prior to the scheduled duty, verified and approved by the Program Coordinator and the Dean of the Midwifery Department.
- Courtesy call should be made to Barangay Officials and Personnel, familiarizing oneself with their names and faces.
- Ocular survey of the area should be conducted.
- Spot map should be created, including directions (N, E, W, S), resources in the community, and the location of the Barangay Hall, School, Market, Church, Public faucet, Public toilet, etc.
- Qualified family clients should be identified.
- Home visits are conducted to assess family health and provide essential services.
Pre Visit Phase
- Contacting the family involves determining their willingness for a visit and setting an appointment.
In Home Phase
- Greeting involves acknowledging family members with greetings and introducing oneself.
- Establishing rapport involves engaging in short social conversations.
- Stating the purpose of the visit clearly communicates the reason for the visit.
- Conducting assessment involves using interviews, physical examination, and simple diagnostic exams.
- Observing family dynamics and physical environment provides insights into the family's functioning and living conditions.
- Using the standard family assessment form ensures consistency in data collection and analysis.
Family Data Analysis, Diagnosis, and Plan of Care
- Family Data Analysis involves interpreting the collected data to understand the family's health status and any contributing factors.
- Family Diagnosis identifies the specific health issues or needs of the family.
- Plan of Care involves setting priorities, establishing goals and objectives, and determining interventions to achieve those goals.
Implementation of Care
- Physical Care involves providing appropriate health services, including procedures and treatments.
- Health Teachings educate family members on health-related topics and preventive measures.
- Counseling provides emotional and practical support to family members.
- Aseptic practices like handwashing before and after touching family members are implemented.
- Family teaching involves demonstrating practical methods of preventing the spread of infection.
- Summarizing the visit involves reviewing key points with the family, and setting a date for a subsequent visit.
Post Visit Phase
- Documentation involves recording events that transpired during the visit, including personal observations and feelings.
Family Assessment: Initial Data Base
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Family structure, characteristics, and dynamics include:
- Members of the household and their relationship to the head of the family.
- Demographic data (age, civil status, position in the family).
- Place of residence (whether living with the family or elsewhere).
- Family structure type (nuclear, extended, blended).
- Dominant family members involved in decision making, especially in health care.
- General family relationships and dynamics.
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Socio-economic and cultural characteristics include:
- Income, occupation, and place of work for each member.
- Educational attainment of each member.
- Ethnic background and religious affiliation.
- Significant others and their roles in the family's life.
- Family's relationship to the larger community (membership in organizations).
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Home and environment include information on housing and sanitation facilities, including:
- Housing agency, sleeping arrangements, food storage, cooking facilities, water supply source, ownership, potability, presence of accident hazards, toilet, garbage disposal.
- Availability of social, health, communication, and transportation facilities in the community.
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Description
Test your knowledge on the critical components of health history, including demographic data, chief complaints, past medical history, and psychosocial assessments. This quiz also explores the importance of reviewing literature in healthcare for better patient outcomes.
